Factors Influencing Medication Adherence among Individuals with Schizophrenia: A Qualitative Meta-Synthesis Based on the Ecological Model

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J Korean Acad Psychiatr Ment Health Nurs. 2025;34(1):40-53

Publication date (electronic) : 2025 March 31

doi : https://doi.org/10.12934/jkpmhn.2025.34.1.40

Sukyung Son¹, Eunyoung Park^,2

¹Graduate Student, College of Nursing, Chungnam National University, Daejeon, Korea

²Associate Professor, College of Nursing, Chungnam National University. Daejeon, Korea

Corresponding author: Park, Eunyoung College of Nursing, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea. Tel: +82-42-580-8323, Fax: +82-42-580-8309, E-mail: eypark@cnu.ac.kr

- This study was supported by Chungnam National University Hospital Research Fund in 2022 (Grant Number: 2022-0542-01).

Received 2025 February 22; Revised 2025 March 6; Accepted 2025 March 21.

Abstract

INTRODUCTION

METHODS

4. Study Selection

A literature search was conducted by two researchers (EP and SS) who independently screened the articles for duplicates and eligibility. Disagreements were resolved through discussion. The database search initially identified 6,043 studies, of which 2,324 were duplicates. The title and abstract screening of the remaining 3,719 studies excluded 3,694 studies that did not employ qualitative research methods. Full-text reviews of the remaining 25 studies led to the exclusion of 16 studies that did not examine patients with schizophrenia and six that did not focus on medication adherence. Ultimately, three studies were selected. The study selection process is illustrated in Figure 1.

Fig. 1.

Flowchart of the search process.

RESULTS

1. Study Characteristics

This qualitative meta-synthesis included three studies published between 2011 and 2020, all conducted in South Korea. Forty participants (17 men and 23 women) were included. One study exclusively recruited women with schizophrenia (A1), whereas the other two included both men and women (A2 and A3). Participant ages varied across the studies. One study reported the age distribution of two participants in their 30s, five in their 40s, and two in their 50s (A1). Another study indicated an age range of 26~63 years (A2), whereas another reported an average age of 46.7 years (A3). Regarding the methodological approaches, two studies employed a phenomenological design (A1 and A2), whereas the third study did not explicitly specify its methodological approach (A3). Data were conducted through in-depth interviews. Two studies used semi-structured interviews (A1 and A3), while one employed an unstructured interview approach (A2) (Table 1).

Table 1.

Characteristics of the Included Studies

2. Quality Assessment of Included Studies

The quality assessment of the studies, based on the CASP Checklist, is presented in Table 2. Two researchers independently evaluated the studies and resolved discrepancies through discussion and consensus. One study did not specify the participant recruitment process (A3). In two studies, data saturation was not addressed during data collection (A2 and A3). Additionally, none of the three studies fully addressed Item 6 of the CASP Checklist, which concerns the researcher-participant relationship. Regarding ethical considerations, one study failed to mention Institutional Review Board approval (A2) and another did not provide any details on ethical considerations (A3).

Table 2.

Quality Assessment of the Studies

3. Meta-Synthesis

The synthesis of the three studies on medication adherence in individuals with schizophrenia identified five key themes, identifying both barriers and facilitators, within the framework of the ecological model. These themes spanned multiple factors: intrapersonal factors (barriers: lack of insight and perceived burden of taking psychiatric medication; facilitators: acceptance of medication as treatment), interpersonal factors (facilitators: supportive systems), and community factors (barriers: stigma related to the use of psychiatric medication) (Table 3).

Table 3.

Synthesized Themes of Factors Influencing Medication Adherence among Individuals with Schizophrenia

1) Intrapersonal factors

(1) Lack of insight

Patients with schizophrenia sometimes refused to take their medication because they did not acknowledge their mental illness. Even when they recognized the importance of medication, they discontinued it for no specific reason. Additionally, some patients avoided taking medication because of concerns about long-term use or fear of negative evaluations from their families. The lack of perceived effectiveness or absence of noticeable symptom improvement was also a barrier to medication adherence. Another factor that impeded medication adherence was insufficient information during the initial stages of treatment, which led to the misinterpretation of side effects as new symptoms.

① Limited understanding of medication

Patients with schizophrenia sometimes discontinued their medication without a specific reason (A1), driven by curiosity about the relapse of improved symptoms (A1) or the belief that they could manage their symptoms without it (A2). Despite understanding the importance of medication, some patients temporarily stopped taking the medication to observe its effects (A1). Others, even though they were aware that discontinuation could worsen their symptoms, believed they could control their condition independently and thus stopped taking their medication (A2). Additionally, some patients avoided medication entirely because of their perception that they did not have a mental illness (A3).

By taking my medication every single day without missing a dose, I felt fine. But I wanted to see if my symptoms would come back if I stopped taking the medication. I thought, 'Maybe I can be okay without the medication', so I stopped... After a while, I ended up being hospitalized. (A1)

I anticipated that problems would arise if I stopped taking my medication. I thought I could handle it. I thought, 'Let's try it. Let's try not taking the medication once.'... But the medication the hospital gives me is brain medication. It doesn't cure a physical illness, but rather helps my mind function properly. (A2)

② Negative attitudes toward medication

Study participants demonstrated misunderstandings regarding psychiatric medications. Patients with schizophrenia were hesitant to take medications, fearing that long-term use could shorten their life expectancy (A1). Additionally, some patients reported that their families perceived them as less intelligent after taking the medications (A3).

I don't want to take my medication. I've been taking it as regularly as my meals. I want to live a long life. People say that taking medication will shorten my lifespan. (A1)

My family says I seem less dumb because I take medication. (A3)

③ Skepticism about medication effectiveness

Participants discontinued their medication because of a perceived lack of effectiveness and persistent symptoms (A2), which led to frustration and dissatisfaction with the treatment (A3). They reported that, while taking the medication initially made them feel comfortable and less irritable, they eventually saw no reason to continue. As they did not experience any problems or noticeable changes, they stopped taking the medication (A2). One participant expressed dissatisfaction, noting that their psychiatric symptoms persisted despite taking the medication (A3).

After taking it (medication) for about six months, I started feeling comfortable and no longer angry. But I saw no reason to continue taking it. I thought, 'It's the same whether I take it or not.' ... By taking the medication and remaining still and quiet, I felt no problems or discomfort, so I ultimately stopped taking it. (A2)

I still have lingering symptoms that don't go away, so I feel somewhat dissatisfied with the medication. (A3)

④ Challenges in obtaining accurate information

The participants faced significant challenges in obtaining accurate information about their illnesses and medications during the initial stages of pharmacological treatment. They reported that the lack of sufficient information regarding the effects and side effects of these medications was a barrier to consistent medication adherence (A1). Furthermore, this lack of understanding led some participants to misinterpret the side effects of medication as symptoms of another illness (A3).

My body was so exhausted… and I was staggering and unable to control myself. If it were now, I would understand that this is a side effect of the medication that makes me suffer. At that time, it was my first experience with psychiatric medication, so I didn't know why my body was reacting this way. (A1)

When I first developed symptoms, I didn't even realize they were auditory hallucinations. Even after discharge, I still didn't understand my illness. I thought the side effects might be related to another condition, so I kept asking for brain surgery. (A3)

(2) Perceived burden of taking psychiatric medication

Participants discontinued their medication owing to various side effects that adversely affected their daily functioning and reduced their willingness to engage in social activities. Furthermore, apprehension about the potential side effects of medication adjustments, combined with the ongoing nature of long-term medication adherence, poses a significant barrier to adherence to medication regimens.

① Discomfort and anxiety in daily life due to side effects

Patients with schizophrenia discontinued their medication because of side effects such as tongue stiffness, slurred speech, dry mouth, and hand tremors. They perceived that these side effects hindered simple tasks such as eating or holding utensils and led to ridicule from others, which reduced their motivation to continue the medication (A1). Moreover, some participants refused to take medication because weight gain reduced their self-confidence, leading to avoidance of social activities (A2). Patients also expressed concerns about potential side effects associated with medication changes (A3).

My hands trembled after taking the medication, sometimes even while holding a spoon. I thought it was because my muscle strength was decreasing. (A1)

While taking the medication, my tongue became stiff, and my mouth kept getting dry. A woman in another hospital room mimicked the way I spoke, and others teased me as well. (A1)

When I took the medication, I felt constantly drowsy, and my weight suddenly increased by 17 kg. I didn't want to do anything, became increasingly lazy, and felt too overweight to go outside. (A2)

② Fear of long-term medication use

Patients avoided taking medication because of fear and concerns about lifelong use. They worried about the potent effects of psychiatric medications causing adverse side effects, potentially harming their physical health. This fear contributed to the perceived burden of taking medication daily for the remainder of their lives (A2).

Even if I might seem foolish, I understand that the medication can be harmful. I'm worried about my body. I keep thinking, 'Wouldn't it be burdensome to take cold medicine once a day for a year? Then, how could I handle taking this (psychiatric medication) like this for life?'. (A2)

(3) Acceptance of medication as treatment

Patients with schizophrenia perceived that improvements in symptoms, such as reduced anxiety and enhanced emotional stability, were key factors in promoting medication adherence. In addition, experiences of symptom relapse following medication discontinuation reinforced the perceived necessity of adherence. Over time, the patients' growing recognition of the critical role of medication in managing their condition further supported consistent medication adherence.

① Perceived improvement in symptoms

Participants demonstrated consistent adherence to their prescribed medication regimen, attributing this to direct experiences of reduced tension and anxiety, a sense of calm, and improved control over impulsive behavior (A2). One participant reported that their mind felt more stable, which significantly reduced their intrusive thoughts (A3). Additionally, participants perceived mild side effects, such as dry mouth, as significantly less distressing than the intense anxiety symptoms they had previously experienced, which reinforced their decision to continue taking the medication (A1).

When I visited crowded places like the market, I felt so tense that my mouth became distorted, and it seemed like my teeth might break. I also felt restless and anxious. While walking down the street, I would get angry, feel the urge to kick objects, and even have thoughts of harming others. However, after taking the medication, these symptoms disappeared, and I felt more stable. (A2)

When I take the medication, I feel calm and stable, my mind becomes clear and positive. Unnecessary thoughts decrease, symptoms improve, and I feel normal. (A3)

② Efforts to prevent relapses

Participants reported taking medication to prevent physical discomfort, such as slurred speech and difficulty articulating words, which occurred when they missed a dose (A2). They perceived notable differences in their symptoms with and without medication, recognizing the importance of preventing relapse and maintaining their daily functioning. Additionally, while they initially believed that their mental state had improved after discontinuing medication, the experience of worsening symptoms further strengthened their commitment to continue medication use (A3).

Sometimes I forget to take my medication. When that happens, my tongue gets twisted, and I can't speak naturally. (A2)

Skipping medication leads to relapse while taking it helps prevent it. Preventing relapse through medication is essential for maintaining a normal life. (A3)

When I stopped taking the medication, I initially felt better, but my condition worsened, so I started taking the medication regularly again. (A3)

③ Recognition of the necessity for medication adherence

The participants initially exhibited reluctance toward medication. However, viewing medication as similar to taking vitamins for managing psychiatric symptoms helped maintain consistent adherence (A2). Over time, participants began to recognize their essential role in their treatment (A3).

I think of it not so much as medicine, but more like a drink or a vitamin. I need to keep taking it regularly from now on. I don't want to take it, but it feels like I'm taking it out of habit. (A2)

In the early stages of my illness, I didn't receive any education and didn't understand the importance of the medication, but over time, I realized that I needed it. (A3)

2) Interpersonal factors

(1) Supportive systems

The participants' adherence to medication was sustained by the consistent support of family members, who played a crucial role in ensuring compliance with the prescribed treatments. They also emphasized that proactive interventions, such as medication adjustments and regular consultations with healthcare providers, helped maintain consistent medication adherence.

① Encouragement from family members

The participants stated that familial support was essential in motivating them to understand the importance of medication adherence and continuity of their medication treatment. When they expressed doubts about the necessity of the prescribed medications, their parents consistently highlighted the risk of relapse, emphasizing the importance of regular medication intake (A2). Furthermore, when participants were reluctant to take their medications, family members played a key role by facilitating timely administration, which significantly contributed to consistent adherence (A3).

When I wondered, 'Do I really need to take medication? Maybe I don't have to,' my father said, 'You must take it to prevent a relapse,' and he made sure I took my medication every day. (A2)

When I first started taking the medication, I didn't want to, but I eventually did because of my parents' encouragement. (A3)

② Proactive intervention by healthcare providers

Participants reported that when side effects such as excessive drowsiness occurred, healthcare providers adjusted their medication, leading to symptom improvement and enhanced treatment efficacy. Additionally, participants mentioned that healthcare providers emphasized the importance of consistent medication adherence during discharge and encouraged them to take their medication regularly (A2). This guidance motivated the participants to adopt systematic approaches, such as documenting medication dates and meticulously managing their medication schedules, which they found highly beneficial in maintaining adherence (A2).

I told the doctor that the medication was making me sleep too much, which was uncomfortable. Then, the doctor adjusted the medication, which led to an improvement in my symptoms. (A2) When I was discharged, the doctor said, 'If you take your medication consistently, you won't be hospitalized again, so make sure to take it.' Because of this, I keep track of my prescription dates and get my medication on time. (A2)

3) Community factors

(1) Stigma related to the use of psychiatric medication

Participants perceived taking psychiatric medication as shameful, which made them reluctant to adhere to their medication regimens. Another reason for their dissatisfaction with medication was societal misunderstandings and prejudices regarding mental illness and medication use, which led to the loss of friendships and restrictions on expressing their opinions within their families.

① Self-stigma about medication adherence

Participants demonstrated a notable reluctance to adhere to their prescribed medication regimens, as taking medication served as a constant reminder of their illness, potentially exacerbating psychological distress (A2). Moreover, they articulated that taking medication contributed to self-stigmatization, which created barriers to interacting with individuals perceived as mentally healthy (A2). The participants expressed feelings of shame regarding their mental vulnerability, and this discomfort with pharmacological intervention emerged as a significant barrier to medication adherence (A3).

Taking my medication constantly reminds me of my illness, making it feel inconvenient and burdensome, and I don't want to take it. (A2)

I feel ashamed to take medication because it means I'm not normal. (A3)

② Social prejudice and discrimination

Participants avoided taking medication due to widespread misconceptions and prejudices regarding mental illness and psychiatric medication, which caused significant psychological distress (A3). Additionally, after disclosing their medication use, the participants lost contact with friends and were unable to express their opinions or participate in family activities (A3).

(Regarding taking medication) When I told my girl (or boy) friend about it, we broke up. I also shared it with some of my other friends, but they stopped reaching out to me afterward. (A3)

Some members of the general public don't fully understand mental illnesses or treatments, and they have prejudices against taking medication, which makes it difficult for me. (A3)

DISCUSSION

We conducted a comprehensive qualitative analysis of the factors influencing medication adherence among individuals with schizophrenia using an ecological model as a theoretical framework. Synthesizing the findings of these three studies provides a deeper understanding of the complex and multifaceted nature of medication adherence in this population, which often exhibits low adherence or non-adherence. Based on the principles of the ecological model, the three distinct barriers and facilitators affecting medication adherence were identified. These findings highlight the intricate interplay among intrapersonal, interpersonal, and community factors in shaping adherence behaviors in individuals with schizophrenia.

First, among intrapersonal factors, significant barriers schizophrenia included a lack of insight into and the perceived burden of taking psychiatric medication. Owing to limited understanding of their treatment regimen, negative attitudes, and skepticism toward medication, many patients impulsively discontinued their medication, leading to poor prognosis, disease progression, and relapse. A previous study suggested that individuals with mental illness often believe that their symptoms can improve without medication [6]. A common reason for discontinuation is the belief that they do not have a mental illness, making them question the necessity of treatment [18]. Concerns regarding the long-term effects of medication, particularly its impact on life expectancy and cognitive function, further contribute to resistance. Non-adherence to antipsychotic medication is often driven by fear that the medication may be harmful as well as cognitive and attitudinal changes resulting from pharmacological treatment [6]. These concerns reinforce the reluctance toward adherence. Insufficient information about the medication hindered the participants' understanding of their treatment, which in turn reduced adherence levels [19]. Therefore, mental health nurses should develop strategies to enhance medication adherence by providing individuals with schizophrenia with accurate and practical information on treatment and medication. Such education can help foster insights into illness, reduce negative perceptions and prejudices about medication, and ultimately improve adherence by addressing individual factors.

The perceived burden of long-term psychiatric medication presented another significant barrier to intrapersonal factors. Many patients experienced discomfort and anxiety in daily life due to side effects, such as weight gain and neuromuscular symptoms. They also feared lifelong dependence on medications, believing that it might be detrimental to their health. Side effects are one of the most common reasons for non-adherence among individuals with mental disorders [20]. Heightened concerns or negative past experiences related to medication often lead to a substantial decline in adherence [21]. Therefore, within intrapersonal factors, reducing the perceived burden of psychiatric medication requires a personalized, patient-centered approach. Mental health nurses should assess each patient's unique experiences with side effects and their impact on daily life, providing tailored interventions to enhance self-management strategies and minimize discomfort. Additionally, addressing the patients' fear of longterm medication use during consultations can help alleviate anxiety and improve adherence.

On the other hand, under intrapersonal factors, the acceptance of medication as a form of treatment was a key facilitator of medication adherence. Individuals with mental illness exhibit higher rates of medication adherence when they acknowledge their condition and recognize the value of medication treatment [22]. Some patients perceived noticeable symptom improvements, including reduced anxiety, increased mental stability, and better impulse control, after initiating psychotropic medication. In a previous study, approximately 11% of patients experienced significant reductions in hallucinations and an overall improvement in functioning due to medication use [19]. The patients also recognized the importance of medication in preventing relapse. They reported physical discomfort and exacerbated symptoms when skipping doses, which reinforced their commitment to adherence. This aligns with existing research indicating that non-adherence to antipsychotic medication is common among individuals with schizophrenia and is strongly associated with an increased risk of relapse [5].

Moreover, recognition of the necessity for medication adherence emerged as a crucial factor. Patients acknowledged the importance of continuing medication based on their personal experiences of symptom exacerbation, hospitalization, and overcoming the fear of side effects. Patient motivation is pivotal in promoting adherence, as greater awareness of medication benefits enhances commitment to treatment [13]. Furthermore, reflecting on positive treatment outcomes, recognizing symptom stabilization, and observing the negative consequences of non-adherence in others have been identified as significant contributors to sustained adherence [18]. Considering these factors, mental health nurses should play a key role in helping patients gain insight into their illness by experiencing symptom improvement through continued medication use, thereby realizing the necessity for medication adherence and acceptance of treatment.

Second, regarding interpersonal factors, family support and proactive involvement of healthcare providers played a key role in medication adherence among individuals with schizophrenia. Family members were instrumental in ensuring adherence by providing reminders, offering assistance, enhancing the patients' understanding of their treatment regimens, and reducing the risk of non-adherence. These findings are consistent with those of previous studies that have identified family support as a key facilitator of medication adherence [6,19,23]. The presence and active involvement of family members facilitates medication monitoring, supports adherence, and allows for early detection of potential relapse episodes [18,23]. To improve medication adherence in individuals with schizo phrenia, it is crucial to educate both patients and their families about psychiatric medications, including their effects, potential side effects, and management. Enhancing family involvement improves patient adherence and treatment outcomes [23]. In addition, the therapeutic alliance between healthcare providers and patients is essential for improving medication adherence, as it fosters emotional support and provides patients with comprehensive information [24]. However, negative experiences, such as perceived criticism, insufficient clarity regarding medications and their side effects, and disagreements over treatment approaches, can lead to mistrust between patients and healthcare providers [24]. This mistrust may result in patients withholding information about their medication use or reducing the frequency of medical visits, ultimately undermining the effectiveness of their treatment regimen [24]. To enhance medication adherence in patients with schizophrenia, a trust-based relationship with healthcare providers and active family involvement are essential interpersonal factors. To this end, healthcare providers should actively engage with patients, listen to their perspectives, foster open communication, provide clear and comprehensive medication information, and offer emotional support [18,24].

Third, regarding community factors, participants perceived that taking psychiatric medication caused feelings of shame, reduced social interaction after disclosing their medication use, and created a sense that their family members disregarded their opinions, ultimately leading to medication avoidance. A previous study identified stigma from family, neighbors, and the community as significant barriers to consistent medication adherence among individuals with psychiatric disorders [6]. Some individuals avoided taking medication in public because of concerns about revealing their mental illness, which led them to prefer internal medicine clinics over specialized psychiatric services [25]. Consequently, such stigma not only restricts access to essential mental health resources but also contributes to decreased medication adherence [25]. Supportive healthcare policies and a more accepting social environment play pivotal roles in enhancing medication adherence and reducing stigma among individuals with schizophrenia [26]. Media representation also significantly influences societal perceptions of mental health. Media coverage can help reduce the stigma associated with psychiatric disorders [27]. Individuals with chronic illnesses may struggle with medication self-management owing to stigma-related fear. Therefore, community mental health nurses should adopt a non-judgmental approach and engage in open discussions on medication-related barriers and concerns [13]. Reducing both social and self-stigma related to psychiatric medication requires an in-depth understanding of patients' perspectives on their mental illness and treatment [28]. Public awareness campaigns are critical for improving societal attitudes toward psychiatric medications. Positive media portrayals of mental illness play a crucial role in fostering a more informed and accepting society by actively challenging stigma and prejudice [27]. Thus, in the community, continuous monitoring and critical analysis of media representations of psychiatric medication treatment are necessary to prevent the reinforcement of stigma and misinformation. Furthermore, considering the unique sociocultural context of South Korea, efforts should be made to promote accurate information, foster awareness, and support individuals receiving treatment. Applying an ecological model to understand the interactions at various levels-individual, community, and societal-can offer a comprehensive approach to mitigating stigma and improving treatment adherence.

This study was conducted across three domestic studies, which may limit its ability to fully capture the diverse and multifaceted factors that influence medication adherence among individuals with schizophrenia in different cultural and international healthcare contexts. These factors can vary significantly across sociocultural backgrounds and require careful consideration when applying these findings to diverse settings. There is a pressing need for further research that incorporates an international perspective to understand medication adherence experiences across various cultural backgrounds and healthcare systems. While this study synthesized multiple studies, it is important to acknowledge that some context-specific nuances intrinsic to individual studies may have been overlooked, potentially overlooking subtle yet significant factors that influence medication adherence. Despite these limitations, this study is significant because it provides a comprehensive and integrated exploration of the factors affecting medication adherence in individuals with schizophrenia in South Korea, utilizing a qualitative meta-synthesis methodology. Furthermore, by examining the barriers to and facilitators of medication adherence under intrapersonal, interpersonal, and community factors using an ecological model, this study offers valuable insights into the necessity of multilevel interventions aimed at promoting sustained medication adherence.

CONCLUSION

Barriers to medication adherence due to intrapersonal factors include insufficient knowledge, negative perceptions of medication, doubts about its effectiveness, and difficulty in accessing reliable information. Concerns about side effects and long-term use of psychiatric medications have also hindered adherence. Conversely, facilitators of adherence include symptom improvement, relapse prevention, and recognition of medication as essential for managing the condition. Among interpersonal factors, family support and the proactive involvement of healthcare providers play a crucial role in fostering sustained adherence. Regarding community factors, the discontinuation of medication among individuals with schizophrenia is primarily driven by internalized stigma and prevailing social prejudice. These findings highlight the need for a comprehensive, multifactor approach that addresses intrapersonal, interpersonal, and community factors to enhance medication adherence. This approach should incorporate tailored medication education, active family involvement, proactive communication with healthcare providers, and supportive policies aimed at reducing stigma. The insights from this study are expected to serve as foundational data for the development of targeted intervention programs designed to improve medication adherence in patients with schizophrenia.

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